F0689

D

Failure to Implement Ordered Fall-Prevention Measures and Complete Post-Fall Risk Evaluations

Los Angeles, California Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain ordered fall-prevention interventions and to complete required fall risk evaluations for residents identified as being at high risk for falls. One resident with severe cognitive impairment, poor safety awareness, and a documented history of unwitnessed falls had physician orders and IDT recommendations for floor mats to be placed on both sides of the bed following a fall. Despite these orders and the facility’s fall management policy, surveyors observed that no floor mats were at the bedside; instead, a single fall mat was stored behind the room door. A CNA reported that only one mat was used and that she typically removed it during the day shift, and an LVN stated he was unaware of any floor mat orders and had not ensured their implementation, even though the LVN job description required carrying out physician orders.

The same resident had additional physician orders for a bed alarm and wheelchair alarm after another unwitnessed fall, and the care plan directed staff to monitor, document, and report changes in the effectiveness of these alarms. Multiple subsequent assessments, including a change of condition assessment and a rehab post-fall screen, documented that alarms and floor mats were not in place at the time of later falls and that the resident continued to exhibit confusion, impulsiveness, forgetfulness, and poor safety awareness. Staff interviews revealed that CNAs and LVNs had not observed the resident using bed or wheelchair alarms, and one LVN acknowledged that the resident had a known pattern of removing and dismantling alarms, but this behavior had not been documented or reported to the physician until months later. The ADON stated that the physician should be notified when a resident refuses ordered alarms so that the plan of care can be reviewed and other interventions considered, and the facility’s fall protocol required staff to monitor and document resident responses to fall interventions.

A second resident, also with severe cognitive impairment and requiring supervision or touch assistance for bed mobility and transfers, experienced an unwitnessed fall in the dining room, after which she complained of right knee pain. Although the facility’s fall clinical protocol required staff to re-evaluate the situation and reconsider fall interventions after any fall, and the ADON stated that a Fall Risk Evaluation should be completed immediately or within 24 hours following any fall, no Fall Risk Evaluation was completed for this resident after the incident. The ADON confirmed that the assessment was not done and acknowledged that it should have been completed to promptly identify interventions to prevent further falls.